More women, and especially more premenopausal women, are surviving their cancer diagnosis. However, due to their therapy, these women may become symptomatic from iatrogenic ovarian failure. For some, the use of hormone replacement therapy (HRT) is contraindicated because it may affect the course of their disease. Other women and their physicians may feel uncomfortable with the use of hormones because research is inconclusive regarding long-term survival or disease recurrence. Women who experience a cessation of menses due to adjuvant therapy for breast cancer are more likely than women undergoing a natural menopause to experience severe hot flashes, night sweats, and fatigue.[1] However, nonhormonal interventions appear to benefit many of these women[2] and should be used to decrease their symptoms. Barton, Loprinzi, and Gostout address these concerns in their excellent review and offer recommendations for pharmacologic and nonpharmacologic interventions.
Vasomotor Symptoms
The treatment of hot flashes, probably the most common symptom associated with menopause, is addressed in detail. In particular, the dosing information on venlafaxine (Effexor), a selective serotonin-reuptake inhibitor (SSRI), is helpful. A number of other SSRIs are also being investigated for the abrogation of vasomotor symptoms, not only in breast cancer patients but also in men with prostate cancer undergoing hormonal therapy. The SSRIs appear to be most effective in controlling these symptoms.
However, side effects of SSRIs include difficulties with sexual arousal and orgasm. This may complicate the treatment of other menopausal symptoms related to sexual function. The authors appropriately mention their concerns regarding the use of progestational agents to treat vasomotor symptoms, and the possible, although unproven, risk of reducing breast cancer survival.
Vaginal Dryness and Incontinence
The management of vaginal dryness is also problematic. The most effective therapies appear to be those that contain estrogen. The amount of estrogen systemically absorbed from either the low-dose estrogen implanted ring (Estring) or the vaginal tablet (Vagifem) is considered small, as discussed in the review. Plasma estradiol(Drug information on estradiol) levels do not increase significantly above baseline in most postmenopausal women, possibly because current assays are not sensitive enough.[3] However, many oncologists and patients may feel uncomfortable with the addition of any amount of estrogen that may be absorbed systemically.
In the excellent section on therapy for urinary incontinence, both stress and urge incontinence are addressed with suggestions offered for pharmacologic, nonpharmacologic, and surgical management of these symptoms. However, it should be noted that the once-promising intervention phenylpropanolamine(Drug information on phenylpropanolamine) is now considered by the Food and Drug Administration to be unsafe for use in women, as it has been associated with an increased incidence of hemorrhagic stroke, especially in younger women. The other alpha-agonists, such as pseudoephedrine(Drug information on pseudoephedrine), have not been associated with this risk and may still be used.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
